Monticello House

In the surveyor’s words

From the most serious findings on record at Monticello House, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jun 18, 2026

  Based on review of facility policy, observations, and staff interviews, it was determined the facility failed to ensure that expired food items stored in the walk-in fridge were properly discarded and a resealed food item was not labeled in the main kitchen.Findings:A review of the facility policy titled Labeling, Dating, and Storage of Food Policy, revised May 18, 2022, revealed the policy requires: All perishable food shall be labeled, dated and stored in a proper and sanitary manner in compliance with state and local regulations to promote fresh and wholesome handling of food; 3. Once a product has been opened (I.e. ground beef, deli meat) it is to be labeled and dated; 4. When labeling food, it must have the name of the food, the date and the expiration date; and 9. […]

• No harm, potential for more than minimal, patternF880May 10, 2024

  Based on observation, clinical record review, and staff interviews, it was determined the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control prevention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were in place for residents requiring enhanced barrier precautions for five of five reviewed (Residents 10, 21, 50, 56, and 58). Findings include: Review of Resident 10's clinical records revealed Resident 10 was admitted to the facility with a diagnosis of left sub gluteal abscess. […]

• No harm, potential for more than minimal, patternF812Jul 13, 2023

  Based on review of facility policy, observations and staff interview, it was determined that the facility failed to prepare food under sanitary conditions in one of four dining rooms. (5th floor) Findings include: Review of facility policy, Single use gloves and hair restraints, policy revised date May 20, 2019, revealed that beard restraints are to be worn if facial hair growth is more than 1/2 inch long. This includes goatees as well. Hair restraints (including hair net or a hat). are to be worn during meal service in the pantries, while food is actively being prepared, served or cooked. Observation on July 10, 2023, at 12:15 p.m. during the lunch meal revealed two dietary staff (E4 and E5) bringing plated food from the pantry without beard guards. […]

• No harm, potential for more than minimal, isolatedF656Jul 13, 2023

  Based on clinical records review and staff interview, it was determined that the facility failed to develop a comprehensive plan of care regarding an exit-seeking behavior for one of the 20 residents reviewed (Resident 60). Findings include: Review of Resident 60's diagnosis list includes Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), mild cognitive impairment, and Depression. Review of the nursing progress notes dated April 20, 2023, at 3:21 p.m., revealed Resident 60 was trying to get into the elevator, resident was informed that she/he cannot leave the floor alone, a resident replied I'm getting off this floor one way or another. […]

• No harm, potential for more than minimal, isolatedF684Jul 13, 2023

  Based on a review of the facility's policy, clinical records review, and staff interviews, it was determined that the facility failed to timely address and notify the physician of a significant weight change of two of the 20 residents reviewed (Resident 28 and 51). Findings include: Review of the facility's policy titled Weights, last reviewed on February 8, 2022, revealed all residents are weighed on admission, weekly x four, monthly as a means of monitoring nutrition. Compare the weight to the last recorded weight, if a gain or loss falls within the parameters below, reweight. […]